What would you do?

[the_alchemist]

Please share your response on this scenario:

Demented geriatric patient fell on concrete floor from wheelchair, sustained a laceration near the corner of the eye and bleeding was controlled. c/o pain in injured area. He is able to mention his name when asked. He is disoriented to time and place, same as baseline. He moves his hands as he has been known to do. Vital signs stable.Neuroassessment done. Pupils round and equal, able to follow objects. No distortion in the face. No fluids coming out of facial openings. Able to move extremities when instructed to do so. Grasps hands when asked to do so, equal. No episode of unconsciousness, no seizure, no sign of distress.

[Asystole RN]

(Copy/paste from previous thread)

Place on 24hr neuro checks, followed by 90 day q-day neuro check, request xray, pt screen/eval, request/monitor labs including UA/INR, monitor airway, reevaluation of medications, assessment of current fall precautions.

History of falls? He is totally baseline?

[Penelope_Pitstop, BSN, RN]

I agree with Asystole, and I'll add increasing frequency of vital sign monitoring (at least for the first 48 hours) and a CT of the head without contrast.

[txspadequeenRN, BSN, RN]

is this ltc? if the laceration needs stitches to the er he goes ...if not ...neuros per facility protocol possible a facial x-ray.... if this is ltc there aint no such critter as a ct or lab monitoring (normally there is a stat and daily service...stat in ltc is defined anywhere from 4hours +) ...first off why did he fall out the wheel chair ...sick, stroke ,trying to walk unsupervised or did the wheelchair turn over cause it got off the sidewalk....establish the reason why his bottom came off the chair and ended up on the ground. then you will know if he needs a pt eval and additional fall precautions....

however if this is a hospital we call everyone just short of the pope and order everything under the sun

[Penelope_Pitstop, BSN, RN]

I'll admit I don't know much about LTC, but I do think this situation would warrant a trip to the hospital, given the elderly's susceptibility for brain bleeds...

[Asystole RN]

I would not think that monitoring labs would be such a drastic thing? Maybe I should have rephrased this, look at his labs and see if there are any subtle changes.

A UA should not be something too difficult to obtain, in my LTC facility I have the ability to run my own through the Urysis scanner. Anytime there is a change of condition in the elderly population I do two things first, check the sugar and run a UA.

A PT screen does not need an order and most LTC facilites have a Rehab floor nowadays with PT/OT, if available why not use?

Just because this is LTC does not mean you have to provide any less care than any hospital. If you cannot treat there then the pt needs to be sent somewhere where he can recieve the treatment he needs. It would be a terrible thing if there was a negative outcome due to a lack of diagnostic tools.

[the_alchemist]

thanks for your responses... btw, it happened in a LTC facility.

given the above assessments, would you call 911? Or would it still be a prudent action to call the Doctor, get an ambulance and send the pt to ER?

[Asystole RN]

thanks for your responses... btw, it happened in a LTC facility.

given the above assessments, would you call 911? Or would it still be a prudent action to call the Doctor, get an ambulance and send the pt to ER?

Assess and call the MD. Given your statements of your assessment I would not send to the ER. Don't forget the reasonable part of the prudent. If the patient is not in distress and you are not noticing anything drastic I would not send out.

Was it a laceration or a skin tear? I only use 911 for codes. I call emergency transport for other emergencies, non emergent transport for non emergencies.

If there was a laceration did pressure stop the bleeding? If it did and it required stitches and not just steri strips then non emergent transport would be called.

[the_alchemist]

to follow up on this thread, unfortunately this patient died. he was sent to the hospital an hour after the fall. he left the LTC facility still alert, with GCS of 14, A&Ox1 same as baseline.

What are your fall protocols in your workplace as far as calling 911 vs non-emergent ambulance?

[Asystole RN]

How soon did he die? Official cause of death?

911 = imminent death or extreme risk of life or limb with no time to ask for permission to send out. Code, uncontrollable bleeding, or if the MD states to send out 911.

non emergent = MD says send out non emergent

[the_alchemist]

he expired about 17hrs after the fall. MD order was to send to ER for further evaluation. No change of condition the whole time pt was in the building. EMTs arrived about an hour after the fall, and exited the building 20 mins later. Like i said, they exited the LTC facility with patient still alert, with GCS of 14, A&Ox1 same as baseline. Now the nurse is being questioned why 911 wasn't called.

[dudette10, MSN, RN]

he expired about 17hrs after the fall. MD order was to send to ER for further evaluation. No change of condition the whole time pt was in the building. EMTs arrived about an hour after the fall, and exited the building 20 mins later. Like i said, they exited the LTC facility with patient still alert, with GCS of 14, A&Ox1 same as baseline. Now the nurse is being questioned why 911 wasn't called.

By whom? What is the fall protocol at this facility?

ETA: The patient died 16 hours after he was transported to the facility? It sounds like he was at the LTC facility for 1 hour after the fall and in the hospital setting for 16 hours after the fall. Is that right?

If so, do those questioning the LTC nurse feel that calling 911 would have saved this patient?

Sounds...weird...to me.